Thanks to the ease of access to healthcare professionals, hospital emergency departments (EDs) have become a primary location where behavioral health patients seek help when their conditions require immediate care. However, EDs are generally designed and operated to treat only a small number of behavioral health patients at a given time. As behavioral health patient counts and severity of conditions increase, ED resources such as beds and staff are quickly depleted, causing many facilities to have larger capacity issues and longer wait times to provide emergency attention to all patients.

One emerging solution is the creation of specialized behavioral health crisis stabilization units (CSUs). These separate units in a hospital are designed and staffed to treat patients with emergency behavioral health conditions and are proving to increase the operational safety, efficiency, and healing outcomes of this growing population by providing the proper environment of care.

Case study: University of Iowa Hospitals and Clinics
In the main ED at the University of Iowa Hospitals and Clinics (UIHC) in Iowa City, Iowa, 8 percent of patients need behavioral health attention. With an average length of stay of 14 hours, this patient type requires three times the typical ED occupancy duration. Additionally, behavioral health patients who are admitted to the hospital extend their time in the ED, with the wait period averaging 18 hours for an open inpatient bed. These longer stays require more attentive staff and lead to reduced turnover of ED rooms, resulting in an increased number of other ED patients leaving the department without being seen. Press Ganey patient satisfaction surveys from UIHC’s ED patient population showed lower quality of care, delays in critical treatment, prolonged discomfort, and increased stress.

The escalating performance deficiencies and strain on this ED led to the recommendation of creating a separate behavioral health CSU. The hospital identified a vacated pediatric intensive care unit that could be renovated into the CSU and would provide access to natural daylight and existing support spaces already configured to provide a functional layout. By using existing space, the $1.1 million UIHC CSU was completed in only eight months after the design process began, opening in October 2018.

Design details
Prior to opening the unit, the only two options for behavioral health patients seeking care in the ED were early and immediate discharge or inpatient admission. Additionally, there was no dedicated psychiatrist and the ED didn’t include ligature-resistant furniture, fixtures, equipment, or spatial considerations to accommodate these patients’ safety. Now, when behavioral health patients arrive in the ED, they receive any necessary stabilization and can then be taken directly to the CSU, which is designed with features to address the safety needs of both patients and staff.

Located on the seventh floor, the 3,185-square-foot unit is organized with spaces identified into three risk occupant zones, each with appropriate design features. For example, high-risk areas comprise spaces where patients can be alone, such as a calming room or bathroom, and are built to the maximum level of safety with inaccessible ceilings and ligature-resistant fixtures and furniture. Areas of medium risk, including the open treatment area and interview rooms, are where patients are always under observation of staff. Here, furniture is weighted and fixtures are tamper resistant, but ceilings are accessible and not all items are necessarily ligature resistant. Staff-only areas are deemed low risk and are built with typical construction methods.

The main treatment room features 12 recliners with 110 square feet of clear area dedicated to each recliner in a communal setting, providing patients with the freedom to move about the room and interact without confinement or restraint. An open provider station helps the staff and patients feel unified and partnered rather than separated during treatment. Furthermore, to encourage socialization and avoid patient degradation that’s often related to isolation, care is delivered in the open treatment area instead of assigned patient rooms.

The unit also has two calming rooms where distraught patients can be isolated at will or with intervention. Although the goal is not to have patients deteriorate to the point of needing an isolated calming room, these rooms are imperative to help de-stimulate an individual patient or to settle situational escalation that could be triggered by social conflict.

By providing an openly social platform with opportunities for games, television, and puzzles, the CSU maximizes patient choices and welcoming inclusive interactions. Other patient amenities, such as a washer/dryer, shower, personal storage lockers, toilets, and activity areas, are located off the open treatment area to give patients a sense of independence and normality while they’re in the unit, a critical step in quicker stabilization and recovery. Additionally, the open design features calming wall graphics, soft pastel colors, and views to the exterior to sooth patients and reduce anxiety or a sense of confinement.

Many safety considerations are integrated into the behavioral health CSU design, as well. The unit is fully separated from other areas of the hospital by a secured vestibule, and patients are brought to the unit from the ED triage area by hospital staff. Patients are then evaluated and processed in the interview/intake rooms prior to being received into the CSU.

Private conversations about patient treatments can occur in a team workroom located behind the provider station, while still allowing staff to maintain visual observation of the unit through a window. Additional design features include pick-proof sealant, weighted furniture, secure TV enclosures, and exterior windows with acrylic shatterproof protection. Ligature-resistant grab bars and fixtures, nonbreakable mirrors, and the elimination of cords or pull devices that could be used as weapons or for self-harm are also integrated into the design.

Lessons learned
After opening its CSU, UIHC saw a 25 percent decrease in behavioral health inpatient admissions, based on the unit’s ability to buffer patients needing more extended stabilization time. The CSU also decreased behavioral health inpatient boarding time from 28 hours to six hours due to fewer patients being admitted. Additionally, UIHC saw a universal decrease in the number of transfers and in the number of emergency patients leaving the ED without being seen (from 7 percent to 1.2 percent), as well as significantly higher patient satisfaction scores, all while avoiding the use of physical restraints.

As the healthcare sector continues to refine this type of behavioral health unit, there are some primary lessons that can be learned from the UIHC’s CSU. For starters, creating a plan for growth is necessary. On opening day, UIHC’s unit was fully occupied and has maintained at least a 95 percent occupancy rate. Second, the physical location of the unit is also critical. At UIHC, the CSU is located seven floors and 1,500 feet away from the ED, presenting operational flow issues due to significant patient travel distances. Proximity to the ED and potential growth areas (soft spaces) that can be converted for future treatment use are important considerations. Additionally, because UIHC’s CSU is for adults only, children and adolescents under the age of 18 with behavioral health conditions stay in the ED. Likewise, any patient with additional medical issues remains in the ED. Separate, adjacent areas for pediatrics and adults that could flex in size also would be a great asset to the unit.

The University of Iowa Hospitals and Clinics’ CSU increasingly demonstrates better treatment for patients, more capacity and reduced walkouts in the ED, a lower percentage of behavioral health inpatient admissions, and overall higher patient satisfaction.

Scott Hansche, AIA, LEED AP BD+C, is director of healthcare at Heery Design, a Slam Studio (Iowa City, Iowa). He can be reached at Hannah Roush, AIA, LEED AP BD+C, EDAC, is a project architect at Heery Design, a Slam Studio (Iowa City). She can be reached at